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Evaluation of Preoperative Cultures Before Second-Stage Reimplantation of a Total Knee Prosthesis Complicated by Infection

A Comparison-Group Study*

Michael A. Mont, M.D., Barry J. Waldman, M.D. and David S. Hungerford, M.D.

Investigation performed at the Division of Arthritis Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, Maryland 21215-5271. E-mail address: rhondamont{at}aol.com
Orthopaedic Specialty Center, 6080 Falls Road, Suite 203, Baltimore, Maryland 21209. E-mail address: bwaldman@mdorthoteam.com.
§Division of Arthritis Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Good Samaritan Professional Building, Suite G-1, 5601 Loch Raven Boulevard, Baltimore, Maryland 21239. E-mail address: dhunger@welchlink.welch. jhu.edu.

Background: Two-stage reimplantation has proven to be highly successful in the treatment of patients with infection at the site of a total knee arthroplasty. However, up to 20 percent of patients have a recurrence of infection following this treatment. The purpose of our study was to determine whether aspiration of the affected joint and culture of the specimen, performed before reimplantation and after discontinuation of antibiotic therapy, would help to identify patients who might have a recurrent infection.

Methods: We prospectively followed sixty-nine patients who were treated for a culture-proven deep infection at the site of a total knee arthroplasty. Group I consisted of thirty-five patients who were treated with removal of the prosthetic components and irrigation and débridement of the joint, followed by six weeks of antibiotic therapy and reimplantation of a prosthesis. Group II was composed of thirty-four patients who were treated with removal of the components and irrigation and débridement of the joint, six weeks of antibiotic therapy, and then repeat culture four weeks after the antibiotic course had ended. If the culture was negative, the patient was managed with a second-stage reimplantation of a prosthesis. If the culture was positive, the protocol was repeated, beginning with irrigation and débridement. The two groups were similar with regard to male-to-female ratio, age, preoperative Knee Society scores, time since primary surgery, types of infectious organisms, duration of symptoms, duration of follow-up, and number of previous revisions. All of the patients were evaluated clinically with use of the objective scoring system of the Knee Society and were followed with serial radiographs. Success was defined as no infection and a functional prosthesis, with a Knee Society score of at least 75 points at the last (thirty-six-month-minimum) follow-up evaluation.

Results: Of the thirty-five patients in Group I, five (14 percent) had recurrence of infection. One of the patients was managed with a successful second-stage revision, three were managed with arthrodesis of the knee, and one continued dwith chronic antibiotic suppressive treatment. Of the thirty-four patients in Group II, three (9 percent) had a positive culture after the course of antibiotics. The protocol was repeated for all three, and they subsequently had a successful second revision. One other patient (3 percent) in Group II, who had a negative culture, had a recurrent infection and was eventually managed with arthrodesis of the knee.

Conclusions: Prerevision cultures, grown after discontinuation of antibiotic treatment and before reimplantation of the components, helped to identify the patients with infection at the site of a total knee arthroplasty in whom the infection might recur. The performance of aspiration and cultures resulted in a substantial improvement in the clinical outcome.

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